The vice president, Senate majority leader, House speaker, surgeon general, and members of Congress were among the first people vaccinated against Covid-19 in the United States. The president-elect, incoming first lady, vice president-elect, and her husband were also vaccinated in the first phase. Yet prioritization frameworks created by expert panels and adopted by states do not grant government leaders any special status, and giving them priority raises important questions of fairness and transparency. As vaccination proceeds, will other political or institutional leaders, or even celebrities and elite athletes, decide that prioritization plans don’t apply to them?
The Advisory Committee on Immunization Practices recommended that health care personnel and residents of long-term care facilities be offered vaccination in the initial phase.1 The Centers for Disease Control and Prevention (CDC) recommended focusing on populations such as those in the critical infrastructure workforce or with increased risk for severe Covid-19 illness.2 The National Academy of Sciences, Engineering, and Medicine (NASEM) framework included first responders and high-risk health care workers in its “Jumpstart” Phase 1a,3 assigning to Phase 2 essential workers in high-risk settings (“workers who are in industries essential to the functioning of society and at substantially higher risk of exposure”3). According to the Cybersecurity and Infrastructure Security Agency, government entities supporting access to health care, conducting public health functions, providing medical care, supporting emergency management, or otherwise supporting the Covid-19 response are essential workers.4
In none of these frameworks do government leaders seem to qualify for Phase 1a. They are neither front-line health care personnel nor residents of long-term care facilities. Whether they must work in settings posing higher transmission risk is debatable at best, and they can protect themselves from exposure in ways health care workers cannot. Government officials fulfill roles important to societal functioning, but the NASEM and CDC recommendations place them in Phase 2.
Non–risk-based factors that merit consideration include ensuring government stability, maintaining national security, and instilling public confidence in vaccination — the stated motivation for former Presidents Bill Clinton, George W. Bush, and Barack Obama to get vaccinated publicly. Surgeon General Jerome Adams said he was vaccinated in Phase 1 in part to address historical distrust of the health care system in communities of color. Widespread cynicism regarding the government’s pandemic-control efforts makes building trust a commendable goal.5 But whether such public demonstrations will generate support for vaccination is uncertain and may not justify diverting vaccines from high-risk populations.
Moreover, providing vaccine first to government officials undermines messaging that has been vital to Operation Warp Speed, violating fairness rules that were promulgated for society. According to the NASEM framework, “Fairness should guide not only the formulation of allocation criteria, but also their application, which should be impartial and evenhanded, avoiding arbitrary exceptions and opportunities for gaming the system.”3 Public health officials making vaccine-distribution decisions should be impartial and apply allocation criteria uniformly, while aiming to mitigate health inequities. Letting government officials jump the queue suggests that they’re more important than other members of society and that the rules don’t apply to them. Given the racial composition of our current leadership, it also runs counter to health equity initiatives. And unlike many essential workers, government leaders probably have rapid access to high-quality care if they become sick with Covid-19, and therefore have lower risk of progression to severe disease.
So can prioritizing government officials be justified — and should upcoming allocation plans therefore prioritize leaders of states or other jurisdictions? Criteria for such prioritization would have to be well reasoned, clearly articulated in advance, and transparently applied.
First, the responsibilities of the leadership role would have to make it vital to the critical functioning of society, rendering the leader’s loss a serious societal threat. A line of succession is typically in place for leaders; it would have to be shown that if a particular leader were incapacitated or died, no successor would be available, or a time lag in filling the role would destabilize government’s functioning. Second, it would have to be shown that other protective measures have uncertain or limited efficacy or are impracticable because of the nature of a leader’s role — and that the leader is adhering to established public health measures to prevent viral spread when possible.
Allocation frameworks would have to define the characteristics of people in “essential leadership” and mandate that officials making allocation decisions apply the criteria transparently. Officials would have to explain who would (or would not) be prioritized and why. Otherwise, we believe, special prioritization of government leaders is inappropriate. Flouting established guidelines, or treating leaders as above them, will only further flame mistrust in government and its future public health responses.
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January 21, 2021 at 05:00AM
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Who Goes First? Government Leaders and Prioritization of SARS-CoV-2 Vaccines - nejm.org
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